GW1-2022-06550_Well Construction - GW1_20220513

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Chris C Russell 14.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
3254 A 40 ft• 605 ft.
ft. fL f
NC Well Contractor Certification Number
15.OUTER CASING for.multi�ased wells`OR LINER if a licable
Russell Well Drilling, Inc, FROM TO DIAMETER THICKNESS MATERIAL
0 ft 55 ft.
6.25 ISDR21 JPVC
Company Name
Well-08-20Z1-155692 16:INNER CASING ORTUBING eothermal:dosed4bo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft,
3.Well Use(check well use): ft. rt. in.
1.7.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.'
❑Geothermal(Heating/Cooling Supply) lilResidential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01ni ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifs licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil4;& gi.size,etc.)
0 ft. 50 fL Dirt
4.Date Well(s)Completed: 05-02-2022 Well ID# 50 ft- 605 ft- Rock
5a.Well Location: fL R
Christopher Compton Sedgewick Homes fL rt.
Facility/Owner Name Facility ID#(ifapplicable) ft ft. MAY
o•
6705 Long Island Rd, Catawba NC 28609 fL ft.
Physical Address,City,and Zip fL ft' I Ptx66"
MR
Catawba 21s REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Cc 'rcation:
35' 39.946' N 081' 01 .901' W 5/9/2022
6.Is(are)the well(s): [11'ermanent or ❑Temporary Signature of Certified Wel Contractor ! Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (it) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if di,[jerent(example-3@200'and 2@100�
10.Static water level below top of casing:40 24a. For All Wells: Original form to Division of Water Resources (DWR),
(R•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Drilled
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR CCPCUA
13a.Yield(gpm) 3 Method of test:Air
Permit Program,1611 MSC,Raleigh NC 27699-1611
13b.Disinfection type: HTH Amount: 1 2/3 cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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